Trends in Initiation of Disease-Modifying Antirheumatic Drugs for Rheumatoid Arthritis Among Commercially-Insured US Adults, 2001-2021

Lydia Lee¹, Jeffrey Sparks², Priyanka Yalamanchili¹, Daniel B. Horton³, Zeba Khan⁴, Joseph Barone⁴ and Chintan Dave⁵, ¹Rutgers University, New Brunswick, NJ, ²Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA, Boston, MA, ³Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy, and Aging Research; Department of Biostatistics and Epidemiology, Rutgers School of Public Health; Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, ⁴Rutgers University, New Brunswick, ⁵Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy, and Aging Research; Center for Health Outcomes, Policy & Economics, Rutgers Ernest Mario School of Pharmacy and Rutgers School of Public Health, New Brunswick, NJ

Meeting: ACR Convergence 2024

Keywords: Pharmacoepidemiology, rheumatoid arthritis

Session Information

Date: Saturday, November 16, 2024

Title: RA – Treatment Poster I

Session Type: Poster Session A

Session Time: 10:30AM-12:30PM

Background/Purpose: Despite the increasing availability of newer RA therapies, there is a paucity of data comprehensively evaluating long-term trends for individual DMARDs in the US. The objective of this study was to evaluate patterns in DMARD initiations between 2001 and 2021 among US adults with RA.

Methods: This retrospective cohort study was conducted using a US commercial claims database from 2001 to 2021. A cohort of patients with RA (≥18 years) newly initiating a DMARD was identified. For each calendar year, we calculated the proportion of initiations for 22 individual DMARDs, also grouped into categories of: conventional synthetics (csDMARDs), biologics (bDMARD), and targeted synthetics (tsDMARDs). Secondary analyses included an examination of trends in the first-line use of non-csDMARDs and the uptake of biosimilars.

Results: We identified 407,728 DMARD initiation episodes among 229,365 unique patients with RA (median age: 50 [IQR, 44-58 years]; 79.4% female subjects). There were shifts in DMARD utilization, with csDMARD use declining from 79.7% of initiations in 2001 to 54.7% by 2021 (p< 0.001 for trend; Figure 1). Meanwhile, bDMARDs and tsDMARDs initiations increased from 20.3% in 2001 to 33.1% in 2021 (p< 0.001) and from 0.1% in 2014 to 12.2% in 2021 (p< 0.001), respectively. Methotrexate remained the most initiated DMARD over the 21-year study period, albeit declining from 28.7% to 15.0% of initiations over the study period (p< 0.001; Figure 2). Adalimumab was the most frequently initiated bDMARD (13.3% in 2003 and 12.2% in 2021; p=0.05). Among tsDMARDs, tofacitinib use peaked in 2019 (8.9%) and declined to 4.4% in 2021, while upadacitinib use increased from 1.2% to 7.6% during the same period (p< 0.001). For secondary analyses, adalimumab was the predominant first-line b/tsDMARD initiated ( >40%), as seen in Figure 3. Uptake of biosimilars remained low (< 1%) throughout the study period.

Conclusion: Our study provides valuable insights into the evolving landscape of DMARD treatment among US adults with RA. While csDMARDs continue to be a mainstay in treatment regimens, their dominance is gradually diminishing in favor of bDMARDs and, more recently, tsDMARDs. This trend underscores the nuanced preferences and trade-offs made by clinicians and patients, balancing considerations of effectiveness, safety, costs, and convenience. As new DMARDs and biosimilars emerge, future research is needed to examine their impact on real-world treatment patterns.

Figure 1 displays the initiation episodes of DMARDs by drug class in adults with RA, 2001_2021. A DMARD claim was considered a new use episode if a patient had no claim for the same DMARD within 1 year prior to the current DMARD claim. Dates of initial FDA approvals of DMARDs for RA are indicated by dotted vertical orange lines.

Abbreviations: DMARD, disease-modifying antirheumatic drug, csDMARD, conventional synthetic DMARD, bDMARD, biologic DMARD, tsDMARD, targeted synthetic DMARD, COVID_19, Coronavirus disease 2019

Figure 2 displays the initiation episodes of DMARDs in adults (≥18 years old) with RA, 2001_2021. A DMARD claim was considered a new use episode if a patient had no claim for the same DMARD within 1 year prior to the current DMARD claim. Only DMARDs representing ≥5% initiations in at least one year are shown in this figure, so the proportions presented here may not sum to 100%. Dates of initial FDA approvals of DMARDs for RA are indicated by dotted vertical orange lines.

Abbreviations: DMARD, disease-modifying antirheumatic drug, COVID_19, Coronavirus disease 2019, HCQ, hydroxychloroquine, MTX, methotrexate, ADA, adalimumab, LEF, leflunomide, UPA, upadacitinib, SSZ, sulfasalazine, ETN, etanercept, ABA, abatacept, TOFA, tofacitinib, INFX, infliximab, ANA, anakinra

Figure 3 displays the first biologic or targeted synthetic DMARDs (b/tsDMARDs) in adults with RA, between 2001 to 2021. Only DMARDs that were ≥5% frequently used in our data are shown in this figure, so the proportions presented here may not sum to 100%. Dates of initial FDA approvals of DMARDs for RA are indicated by dotted vertical orange lines.

Abbreviations: DMARD, disease-modifying antirheumatic drug, ADA, adalimumab, ETN, etanercept, UPA, Upadacitinib, TOFA, tofacitinib, ABA, abatacept, INFX, infliximab, GOL, golimumab, ANA, anakinra, COVID_19, Coronavirus disease 2019

Disclosures: L. Lee: Boehringer Ingelheim, 3, GSK, 3, 12, Fellowship Sponsor, Rutgers University, 3; J. Sparks: Boehringer-Ingelheim, 2, 5, Bristol-Myers Squibb(BMS), 2, 5, Gilead, 2, Janssen, 2, Pfizer, 2, UCB, 2; P. Yalamanchili: AbbVie, 2, Amgen, 2, Boehringer Ingelheim, 2, 5, Bristol Myers Squibb, 2, 5, Gilead, 2, Inova Diagnostics, 2, Janssen, 2, Llura Gund Award for Rheumatoid Arthritis Care and Research, 5, National Institute of Arthritis and Musculoskeletal and Skin Diseases, 5, Optum, 2, Pfizer, 2, R. Bruce and Joan M. Mickey Research Scholar Fund, 5, ReCor, 2, Rheumatology Research Foundation, 5, Sobi, 2, UCB, 2; D. Horton: Arthritis Foundation, 5, Childhood Arthritis and Rheumatology Research Alliance, 5, 12, Salary support, Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01HD109335), 5, National Center for Advancing Translational Sciences (UL1TR003017, UM1TR004789), 5, National Institute of Arthritis and Musculoskeletal and Skin Diseases (R01AR074436), 5; Z. Khan: None; J. Barone: None; C. Dave: FDA, 2, Juvenile Diabetes Research Foundation, 5, National Heart, Lung, and Blood Institute (R01HL163163), 5, Takeda, 2, Veterans Health Administration, 5.

To cite this abstract in AMA style:

Lee L, Sparks J, Yalamanchili P, Horton D, Khan Z, Barone J, Dave C. Trends in Initiation of Disease-Modifying Antirheumatic Drugs for Rheumatoid Arthritis Among Commercially-Insured US Adults, 2001-2021 [abstract]. Arthritis Rheumatol. 2024; 76 (suppl 9). https://acrabstracts.org/abstract/trends-in-initiation-of-disease-modifying-antirheumatic-drugs-for-rheumatoid-arthritis-among-commercially-insured-us-adults-2001-2021/. Accessed .

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